TREATMENT OF Buruli ulcer with antibiotics

The standard antibiotic treatment recommended by the WHO is rifampicin at 10 mg/kg body weight by
mouth daily for 8 weeks and streptomycin at 15mg/kg body weight by intramuscular injection for 8
weeks, this dosage is not applicable for pregnant women. According to Dossou et al, a pregnant patient
in Benin was successfully treated with a combination of erythromycin and clarithromycin. In Australia,
the recommended treatment based on vast clinical practice is rifampicin at 10mg/kg body weight by
mouth daily for 8 weeks and clarithromycin at 7..5 mg /kg body weight by mouth twice for 8 weeks or
rifampicin at 10mg/kg body weight by mouth once daily for 8 weeks and moxifloxacin at 400 mg by
mouth once daily for 8 weeks.

Table 1: Dosage of Rifampicin, Streptomycin and Clarithromycin according to the patient body weight
(WHO, 2012)

Body Streptomycin Rifampicin (300mg/tablet)* once Clarithromycin ** twice daily

Weight of injection (1g) daily (Instant release)
Patient once daily
(kg)
Dos Dose (mg) No. of tablets Daily dose (mg)
e (g)
5-10 0.25 75 0.25 125 5ml
11-20 0.50 150 0.50 250 10ml
21-39 0.50 300 1.00 500 1 tablet
40-54 0.75 450 1.50 750 1.5
tablets
> 54 1.0( maximum) 600 (maximum) 2.00 1000(maximum) 2 tablets
*Rifampicin syrup may be used

**Extended release formulation of clarithromycin may used, at 15mg/ kg once daily.

GUIDANCE AND SUPERVISION OF ANTIBIOTICS SIDE EFFCETS

According to WHO most Buruli ulcer patients complete treatment with no significant adverse effects;
however, a few patients do experience such effects, and it is therefore important that patients be
monitored clinically during treatment so that any adverse effects can be promptly detected and properly
managed (Table 2). Routine laboratory monitoring may not be necessary, but, when it is clinically
indicated, patients should be monitored regularly for adverse effects on the body as a whole (e.g.
by hearing, renal and liver function tests). WHO recommend that health workers can teach patients and
their relatives how to recognize the symptoms of common side-effects and encourage them to report
any such symptoms. Adverse reactions to drugs should be recorded on the back of the BU 01 ( Annex 3)
form or in the patient folder.

Table 2: Symptoms Based Approach to Identifying and managing the side effects of antibiotics
treatment

Common Side Effects Drug probably Management

Skin rash with or without itching Streptomycin Stop treatment
Rifampicin
 Deafness (no wax on Streptomycin Stop streptomycin
othoscopy )
Dizziness (vertigo , ataxia and Streptomycin Stop streptomycin
nystagmus)
Decreased urine output Streptomycin Stop streptomycin
Jaundice (other causes Rifampicin Stop streptomycin
excluded)
Shock, purpura, acute renal Rifampicin Stop rifampicin
failure
Anorexia, nausea , abdominal Rifampicin Stop rifampicin
pains
Nausea, altered taste Clarithromycin Continue treatment, give drugs
with small meals at night before
retiring
Jaundice (other cause excluded) Clarithromycin continue treatment
, hepatitis
Tendonitis Moxifloxacin Stop moxifloxacin
Nausea , anorexia Moxifloxacin Continue treatment
Rash Moxifloxacin Stop treatment
From reference (WHO , 2011). The results of studies suggest that side effects are rare: however, close
monitoring of patients and strict observations of this guidance are necessary.

COINFECTION OF BURULI ULCER WITH OTHRE INFECTIONS

Co-infection with the mycobacteria that cause either tuberculosis or leprosy is uncommon. Any

patient with Buruli ulcer who is co-infected should continue to receive the standard treatment

for tuberculosis or leprosy, but the rifampicin and streptomycin (or other antibiotic) components

of the regimen should be given daily for 8 weeks, after which the standard treatment regimens

for tuberculosis or leprosy should be continued according to the WHO. Buruli ulcer and HIV co-infection

is an emerging area and complicates clinical management. The first case of Buruli and HIV co-infection

was reported from Democratic Republic of the Congo in 1992 (WHO 1997)). A study conducted in Benin

from 2002–2003 found that HIV prevalence among patients with Buruli ulcer was higher (2.6%, 11/426)

than among controls (0.3%, 2/613) (WHO, 2004).In Benin, 6 (3.6%) out of 156 patients treated at Pobè

Buruli Ulcer Treatment Center in 2006 were positive for HIV, and in 2010, 2 (1.5%) out of 135 patients

were HIV positive. In Cameroon, an HIV prevalence of 33% has been reported among adult Buruli ulcer

patients (compared to5% in the general population).HIV weakens the immune system and tends to
make
Buruli ulcer progress more aggressiveand could possibly affect the response to antibiotic treatment. Co-

infected patients are oftenadults (>15 years old) who present with multifocal lesions and osteomyelitis.

Although furtherstudies are required to improve our understanding of this issue, the management of

BU/HIV co-infection may follow the guidelines for managing TB/HIV co-infection. First, HIV counselling

and testing should be offered for all patients presenting with BU. Second, co-infected patients

should be screened for tuberculosis. Thirdly, as for TB, co-infected patients may receive early

antiretroviral treatment to ensure a better response to treatment irrespective of CD4 count.

Due to the interaction between rifampicin and some ARVs, the NNRTI component of the ART

regimen should be changed from NVP to EFV, and if protease inhibitors are being used the

TB/HIV guidelines6 should be consulted for suggested management. The first line of treatment should
be

with rifampicin and streptomycin for 8 weeks. Surgery is usually required to remove nonviable bone and

to hasten healing. The response to treatment can be monitored radiologically

REFRENCES

Dossou AD et al. Management of Mycobacterium ulcerans infection in a pregnant woman in

Benin using rifampicin and clarithromycin. Med J Aust. 2008 Nov 3; 189(9):532-3.

World Health Organization 2012.Treatment of Mycobacterium ulcerans disease (Buruli ulcer)

http://www.who.int/about/licensing/copyright_form/en/index.html).

World Health Organization. Fluoroquinolone use in paediatrics: focus on safety and place in therapy.

Report of the 18th Expert Committee on the Selection and Use of Essential Medicines. Geneva,

2011. http://www.who.int/selection_medicines/committees/expert/18/applications/

fluoroquinolone_review.pdf.
World Health Organization. Treatment of tuberculosis: guidelines for national programmes, 4th Ed.

Geneva, 2009:61.

World Health Organization. Resolution WHA57.1. Surveillance and control of Mycobacterium

Ulcerans disease (Buruli ulcer). In: Fifty-seventh World Health Assembly, Geneva, 17–22 May

2004. Resolutions and decisions, Annexes. Geneva, 2004 (WHA57/2004/ REC/1).

World Health Organization. Working to overcome the global impact of neglected tropical diseases: first

WHO report on neglected tropical diseases. Geneva, 2010

World Health Organization. WHO joins battle against a new emerging disease, Buruli ulcer. Geneva,

1997 (Press release WHO/88)